Charles Janet.

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benefit resulted from their use. I therefore advise you to treasure
them in your memories, as means which will prove most serviceable in
time of need.

The third indication will be fulfilled by means already mentioned
in the treatment of the first stage.

Do all these means ever fail when properly and perseveringly applied;
and does the obstetrician ever see his best-directed efforts end in dis-
appointment ? I regret to answer in the affirmative, but at the same
time express the belief that such failures will be very rare, unless he
has to deal with a very unmanageable patient, or with a case which
had advanced before he saw it to the second stage of mammitis.
Should this stage have arrived, however, before the case came under
his care, or in spite of his efforts to ward it off by checking the first
stage at its inception, he is by no means without resources which may
result in prevention of the third stage, which is the greatest misfortune
that he fears under the circumstances.

Treatment of the Second Stage of Mammitis. — The second stage of
mammitis consists in an effusion of lymph into the areolar tissue of the
mamma; may be recognized by great hardness, pain, tumefaction, red-



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I860.] OCCUBBING DURING LACTATION. 99

11688 and heat, and may well be dreaded as the precursor of abscess,
unless its progress is checked and sappnration prevented.

All those means which have been detailed as applicable to the
disease in its first stage, are to be persevered in in this; but should we
find that, in spite of them, the case progresses steadily towards the
dreaded result of abscess, no time should be lost, but pressure should
be established, with a well-founded hope of successful prevention.

It is now about fifteen years since Trousseau and Contour published
an essay on the treatment of mammary abscess, by compression,
bringing the subject prominently before the profession. Jt was not
original with them, however, for according to Dr. Jas. Gilmour, of
Liverpool, in an excellent article on this subject in the Lancet, already
alluded to, it may be traced to Heister, and its use may be found
alluded to in the works of Pearson, Smellie, and Cooper. In this
city I know of no one who has so systematically resorted to this
means as Dr. S. Conant Foster, who published an excellent article
upon it some four years ago in the New York Jou^mal of Medicine,

In obstinate lacteal engorgements it is very serviceable; even after
pus has begun to form, it relieves pain, and although it does not pre-
vent the coming abscess, seems to prevent the passage of the pyogenic
process to larger parts of the organ ; but in the second stage of mam-
mitis, where engorgement is ending in effusion of lymph, it is certainly
one of the greatest boons with which either patient or accoucheur could
meet.

I have myself repeatedly employed it, and never without being not
only pleased, but surprised by its results. Equable pressure over-
comes the tendency to congestion, keeps the distended follicles closed,
and stimulates the absorbents to great activity. Do not let any the-
oretical objections prevent you from employing this means, and believe
me that you will find it one of the most precious resources which you
can bring to your aid.

The means by which pressure is best effected is by adhesive straps
from 15 to 16 inches in length, and from one to two inches broad.
Suppose, by way of illustration, that the right breast is to be com-
pressed, let the end of the first strip be fixed in the right axilla, and
then being drawn tight, let it be carried over the lower border of the
breast, and its other end attached to the lower border of the breast
on the other side. Then let the second strip be fixed at the upper
border of the left breast, and this being firmly drawn over the lower
border of the right, or diseased breast, let it be fixed so that its lower



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100 MAMMABT ABSCBS3 [AUG.,

end will be attached to the right ride, about three inches below the
origin of the first.

These two strips shonld be longer and wider than those which are
to follow, for they are to give support to the organ. Shorter strips
may follow these, crossing each other as these have done, until the
entire breast is shingled over, as it were, with the compressing cover-
ing. The particular arrangement, however, is a matter of secondary
importance, as the ingenuity of any one will be sufficient to teach
him how to accomplish the desired end. Compress the breast as yon
like, the principle is what I wish to inculcate. Should you desire a
more powerful compressing agent than the straps, a most excellent one «
is offered yon in compressed sponge, as recommended by Dr. Batchel-
der. Having compressed a piece of sponge by heavy weights, place
it on the breast, apply firmly a roller bandage, and through this wet
the sponge. Absorbing water, it will soon swell, and give you a pow-
erful, safe, and equable means of compression. By this very inge-
nious means the hardest tumors will disappear, and the breast be
rapidly reduced in its dimensions. The sponges employed may be
small and numerous, compressing the different parts of the organ
which require such treatment; or one large disk of sponge may be
prepared, with a hole for the nipple, which will act upon the entire
organ at once.

This was the method employed by Dr. Foster in the cases related
in the paper alluded to.

You will often find, in a few hours after pressure has been ap-
plied, that a tumid, hot, and painful breast will change its aspect most
essentially; and even while the straps, or sponge and biiudage, are per-
forming their function, the milk can be dravm by suction, the nipple be-
ing of course left uncovered; and the adoption of the plan does not pre-
vent the continuance of other means, as saline cathartics, antigalactis,
dieting, &c. Pressure, indeed, only takes the place of friction, which
has failed us, or which we cannot employ, from the restiveness of our
patient, or the pain which it induces after mammitis has been alighted.

When pus has formed, nothing more can be done than to encourage
its discharge, and for this purpose a soft poultice should be applied.
So soon as the abscess shows a tendency to point, let it be evacuated,
and then let the whole breast be supported by strapping, only a space
around the opening being left free for the application of a small and
light poultice. The straps, now applied, will prevent the formation of
sinuses, will force out all the contents of the abscess, and cause a
rapid absorption of surrounding effusion.



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I860.] OOOUBBIHa DURIKO LAjOTATIOK. 101

Should obstinate sinases have formed, which will not yield to the
means mentioned, let them be dilated by sponge-tents, injected with
dilute Tr. of iodine, or with simple warm water, and firmly compressed
by means of compressed sponge and a roller bandage.

In reference to these and other chronic pnmlent discharges from the
breasts, I mnst gnard yon against the prolonged nse of poallices.
Like other very nsefal means, they are often abased; and if persevered
in after the proper time, will tend to weaken the diseased tissues, and
encourage the continuance of the exhausting discbarge.

In the medical journals of the day you will see many kinds of
treatment extolled, and the proof of their efficacy which will be addu-
ced will be the fact of their having prevented mammary abscess in
women who have been delivered of still-born children, and have not
nursed. Now, this reasoning is fallacious, for it is very rare that
abscess occurs in such cases, and the prevention is entirely imaginary;
the appearances of threatened abscess having vanished " post hoc,"
but not " propter hoc." I have never seen an abscess of this kind
occur in a woman who had not nursed, although I know that they
sometimes do so.

In concluding, I will give you a rhumi of the means to be adopted
for the checking of a commencing mammitis, without which no
abscess can form, but which is very sure to appear as a secondary re-
salt of uncontrolled lacteal and sanguineous engorgement.

1st. Evacuate the inflamed breast by the breast-pump, or by suc-
tion by the child or nurse, the last being decidedly the best method.

2d. Diminish vascular supply, by saline cathartics, nauseants, direct
sedatives, topical bleeding, and cold applications.

3d. Diminish lacteal secretion by strict diet and antigalactics.

4th. Aid in the accomplishment of all these ends, and at the same
time cause an absorption of effused lymph and serum, by firm and
equable compression.

5th. Never let the inflamed organ hang, but always support it by
means of a long and broad band of adhesive plaster passing nearly
around the body, and thence under the breast.

6th. Avoid poultices and warm fomentations.



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102 PHYSIOLOGY OP THE CIBCULATION. [AUG.,



The Physiology of the Circulation. A Course of Lectures delivered at
the College of Physicians and Surgeons, New York, in the Fall Term
of 1859. By John C. Dalton, Jr., M.D., Professor of Pbysiologj
and Microscopic Aaatomy.

LEgTURB VIII.

(OCTOHIR 4.)

EDdosiDosis and Exosmosis — Experimeat with Endosmometer — Gircamstancee
Regulating EDdosmosis — Condition of the Membrane — Constitution of the
Liquids — Position of the Membrane— Temperature — Pressure — Endosmosis
of Water towards Albumen — Experiment — Nature of Endosmosis— Effect of
Renovation of Liquids by a Current — Experiment — Absorption of Liquids
ft>om Areolar Tissue — Effect of Stopping Circulation — Experiment — Exuda-
tion of Ingredients of the Blood— In Health— In Disease— Rapidity of Endos-
mosis and Transudation in Living Animals — Experiment — Absorption and
Elimination of Poisonous and Medicinal Substances.

Heretofore, gentlemen, we have been occapied with the physical and
mechanical functions performed by the circulatory apparatus. We have
studied the movements of the heart, the texture and properties of the
vessels, and the motion of the circulating current in different parts of
the vascular system. We now approach, however, a different order
of phenomena — those which are more purely physiological in their na-
ture, and which are at least equally important with the others, in the
part which they play in the vital processes of nutrition.

We shall begin to-day with the study of those curiOus phenomena,
exhibited by the animal tissues, which are known as endosmosis and
exosmosis.

These phenomena depend upon the property of two different liquids
which are separated by an animal membrane, of passing through its
substance, and mingling with each other in certain proportions.

If we take, for example, a solution of salt and an equal quantity of
distilled water, and inclose them in a glass vessel with a fresh animal
membrane stretched between, so that there is no direct communication
from one liquid to the other, the two liquids being in contact with
opposite sides of the membrane, it is found after a while that the
liquids have become mixed, to a certain extent, with each other. A
part of the salt will have passed into the distilled water, giving it a
saline taste; and a part of the water will have passed into the saline
solution, making it more dilute than before. If the quantities of the
two liquids, which have become so transferred, be measured, it will be
found that a comparatively large quantity of the water has passed into
the saline solution, and a comparatively small quantity of the saline



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I860.] PHTSIOLOOY OP THE CIRCULATION. 108

solution has passed oat into the water. This abundant passage of the
water, through the membrane, to the salt, is cMedendosmosis; and the
more scanty passage of the salt outward to the water is called ezos-
masis.

It is evident, therefore, that the animal membrane has not prevenlr
ed the mixture of the two fluids. It may even be seen, by farther ex-
amination, that it actually causes the mixture to take place.

I have just said that when the water and the solution of salt are
placed in contact with an animal membrane and pass through it, the
water passes inward to the salt more rapidly than the salt passes out-
ward to the water. The consequence is, that an accumulation soon
begins to show itself on the side of the salt. The saline solution is in-
creased in volume and diluted, while the water is diminished in volume,
and acquires a saline ingredient.

This accumulation of flaid on one side of the membrane takes place
with many other substances when used for a similar experiment.

Here, for example, is an apparatus which will show both the pas-
sage of a liquid by endosmosis through an animal membrane, and its
accumulation on the opposite side.

It consists of a glass vessel, like an inverted funnel, wide at the
bottom and narrow at the top. The bottom of the vessel is closed by
a piece of the mucous membrane of the ox's bladder, which is stretched
tightly over its edge and secared by a ligature. From the top there
rises a very narrow, upright glass tube, several inches in height, and
curved over at its upper extremity, so that its orifice points downward.

Three hours ago this vessel was filled with a strong Folution of sugar,
up to the commencement of the upright tube, and then placed, with
its wide extremity downward, in a vase of distilled water, the mem-
brane being supported in a horizontal position by a perforated metallic
plate.

Since then, the water has been constantly passing by endosmosis,
through the membrane, into the endosmometer. The level of the sac-
charine solution has gradually risen in the upright tube, until it has
filled its entire length, and is now, you observe, constantly dripping from
its superior extremity. A certain amount of the sugar has also passed
out into the water, but this is in such small quantity, comparatively
speaking, that an incessant accumulation has taken place, on the inside
of the membranous septum.

As the saccharine solution, therefore, is much heavier than the wa-
ter, the action of endosmosis has caused this accumulation to take
place against the force of gravity, and has raised a column of the
denser fluid several inches above its former level.



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104 PHTSIOLOOT OF THIS OIROULATION. [AUG.y

As the saccharlDe solution also continnes to drop from the end of
the npright tobe back agaia into the yaae of water, a steady circula-
tion of fluid is kept up by the same force. The water still passes
through the membrane, and accumulates in the endosmometer; but as
this is already full of fluid, the surplus immediately falls back into the
outside vase, and thus a current is established, which will go on until
the two liquids have become intimately mingled.

Now, there are various conditions that influence the extent and ra-
pidity with which this phenomenon of endosmosis takes place.

The first is the freshness of the membrame itself This is an indispen-
sable requisite for the success of the experiment. A membrane that
has been dried and moistened again, or one that has begun to putrefy,
will not produce the desired efifect. It has been found that if the
membrane of the endosmometer be allowed to remain and soak in the
fluids, after the column has risen to a certain height in the upright
tube, it begins to descend as soon as putrefaction commences, and the
two liquids finally sink again to the same level.

The next condition is the extent of contact between the membrane
and the two liquids. The greater the extent of this contact, the
more rapid and forcible is the current of endosmosis. An endosmome-
ter with a wide mouth will produce more effect than with a narrow
one, though the volume of the liquid contained in it be the same in
both instances. The action takes place at the surface of the mem-
brane, and is proportionate to its extent.

Another very important circumstance is the constitution of the two
liquids^ and their relation to each other. As a general thing, if we
use water and a saline solution in our experiments, endosmosis is more
active, the more concentrated is the solution in the endosmometer. A
larger quantity of water will pass inward toward a dense solution than
toward one which is already dilute. But the force of endosmosis va-
ries with different fluids, even when they are of the same density.
Dutrochet, who has written a great deal that is valu ible on this sub-
ject, measured the force with which water passed through the mucous
membrane of an ox-bladder into different solutions of the same density.
He found that the force varies with different substances, as follows:

Endosmosis of water, with a solution of albumen 12

sugar 11

gum 6

gelatine 8

The position of the membrane also makes a difference. With some
fluids, endosmosis is more rapid when the membrane has its mucous



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I860.] PHYSIOLOOT OF THB OIBCULATlOir. 105

I

surfeoe In oontaet with the dense solution, and its dissected sn?face in
contact with the water. With other sabstances the most favon^le
position is the reverse. Matteuoci fonnd that, in nsing the mncon?
membrane of tiie oz-bladder with water and a solution of sngar, if the
mncons surface of the membrane were in contact with the saccharine
solution, the liquid rose in the endosmometer between four and five
Inches. But if the same surface were turned outward toward
the water, the column of fluid was less than three inches in height.
Different membranes also act with different degrees of force. The
effect produced is not the same with the integument of different ani-
mals, nor with mucous membranes taken from different parts of the
body.

Oenerally speaking, endosmosis is more actiye when the temperature
is moderately elevated. Dutrochet noticed that an endosmometer,
containing a solution of gum, absorbed only one volume of water at
a temperature of 32^ Fahr., but absorbed three volumes at a tempera-
ture a little above 90^. Variations of temperature will sometimes
even change the direction of the endosmosis altogether, particularly
with dilute solutions of hydrochloric acid.

Finally, the pressure which is exerted upon the fluids and the mem-
brane favors their endosmosis. Fluids that pass slowly under a low
preissure will pass more rapidly with a higher one. Different liquids,
too, require different degrees of pressure to make them pass the same
membrane. Liebig has measured the pressure required for several
different liquids, in order to make them pass through the same mem*
brane. He found that this pressure was:

For alcohol 52 inches of mercury.

ForoU 81 " '•

For solution of salt 20 " "

Forwater 13 "

You see, then, that in our own experiment, with the water and so-
lution of sugar, the force of endosmosis was very great. For the
pressure of the saccharine solution upon the upper surface of the mem-
brane was much greater than that of the water below; and yet the
water passed through the membrane against this pressure, and accu-
mulated on its upper surface.

There are some cases in which endosmosis takes {^ace without being
accompanied t)y exosmosis. This occurs, for example, when we use
water and albumen as the two liquids. For while water freely passes
in through the animal membrane, the albumen does not pass out.
Here is an egg, with an opening made in the large end of the shell by



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106 PHYSIOLOOT OP THE CIRCULATION. [AUG.,

which the shell-membraDe is exposed. Half an hoar ago the egg was
placed in a goblet of water, and endosmosis has taken place to such
an extent that yon now see the shell-membrane distended, and pro-
truding from the opening in the shell The water has passed into the
egg and dilated the albnmeu, bat there is no albumen in the water of
the goblet, which retains its clear and transparent appearance. The
membrane, therefore, has allowed the water to mix with the albumen
in the egg^ but has not allowed the albumen to mix with the water in
the goblet.

An hour or two later, the accumulation in the egg would have in-
creased to such an extent that the shell-membrane would have been
ruptured by its own distention.

This has actually happened in these two other specimens, which
have remained longer in water than the first. Here, you see, the
shell-membrane has given way, and the albumen and the water are
now mingled in the glass yessel.

Now, gentlemen, we have gone through with the principal phenom-
ena of endosmosis, and have studied the most important conditions
which regulate its action. In the next place, let us see what is the
nature of this process, and what are the essential properties upon
which it depends.

In the first place, endosmosis is not a phenomenon dependent on
the simple force of diffusion or admixture of two different liquids.

It is true that the two liquids become mingled together in all the
examples of endosmosis which I have mentioned. The activity of this
mixture, even, depends very much, as I stated before, upon the
difference in constitution of the two liquids. With water and a saline
solution, for instance, the stronger the solution of salt, the more rapid
is the endosmosis of the water. And if two solutions of -salt be used,
with a membranous septum between them, endosmosis takes place
from the weaker solution to the stronger, and. is proportionate in ac-
tivity to the difference in their densities. From this fact, Dutrochet
was at first led to believe that the direction of endosmosis was deter-
mined by the differenee in density of the two liquids, and that the cur-
rent of accumulation was always directed from the weaker liquid to
the denser. But we now know that this is not the case. For though,
with solutions of salt, sugar, and the like, the current of endosmosis
is firom the lighter to the denser liquid; in other instances, it is the
reverse. * With water and alcohol, for example, endosmosis takes place,
not from the alcohol to the water, but ft'om the water to the alcohol ;
that is, from the denser liquid to the lighter.



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I860.] PHYSIOLOGY OP THB OIBCULATION, 107

The difference in density of the liquids, therefore, is not the only
condition which regulates the direction of the endosmotic current.

The truth is, the process of endosmosis does not depend principally
upon the attraction of the two liquids for each other, but upon the at-
traction of the ammal membrane for the two liquids. The membrane is
not a passive filter through which the liquids mingle, but it is the ac-
tiye agent which determines their passage. The membrane has the
power of absorbing liquids, and of taking them up into its own sub-
stance. This power of absorption, flowing to the membrane, depends
upon the organic or albuminous substance of which it is composed;
and, with different animal substances, the power of absorption is dif-
ferent. The tissue of cartilage, for example, will absorb more water,
weight for weight, than that of the tendons; and the tissue of the cor-
nea will absorb nearly twice as much as that of cartilage.

Beside, the power of absorption of an animal membrane is dififerent
for different liquids. Nearly all animal membranes absorb pure water
more freely than a solution of salt. If a membrane, partly dried, be
placed in a saturated saline solution, it will absorb the water in
larger proportion than the salt, and a part of the salt will, therefore,
be deposited in the form of crystals on the surface of the membrane.

Oily matters, on the other hand, are usually absorbed less readily
than either water or saline solutions.

Ghevrenil has investigated the absorbent power of dififerent animal
substances for dififerent liquids, by taking definite quantities of the
animal substance and immersing for twenty-four hours in the dififerent
liquids. At the end of that time, the substance was removed and
weighed. Its increase in weight showed the quantity of liquid which
it had absorbed. The results which were obtained are given in the
following table:







WoUr.


ScXiMaobaim,


00.


100 parts of Cartilage, 1




[231 parts.


126parU.




»» Tendon,




178 "


114 "


8.6 parts


'' EUstic Ugament,


absorb in


148 "


• 80 "


7.2 "


•» Cornea,


24hoani,


461 **


870 "


0.1 "


<* CartilagiDouB Ligament,
«• Dried Fibrin,




319 "




8.2 "




801 "


164 '*





Tou see, therefore, that the same substance will take up dififerent
quantities of water, saline solutions, and oil.

Now, when an animal membrane is placed in contact with two dif-



Online LibraryCharles JanetAmerican medical monthly and New York review → online text (page 12 of 54)